A comparison of metoclopramide and trimebutine on small bowel motility in humans

Neurological disorders and small bowel dysmotility

PURPOSE OF REVIEW

Small bowel dysmotility is common in the context of neurological disorders. Overlooking it can have an adverse impact on patient's quality of life and neurological outcomes. This review focuses on describing the mechanisms and effects of enteric dysmotility in neurological patients and providing treatment options.

RECENT FINDINGS

Small bowel dysmotility is prevalent among neurological patients. The definition and diagnosis of small bowel dysmotility is a challenge; however, up to two-thirds of neurological patients may experience associated symptoms. Small bowel dysmotility can affect the absorption of nutrients and medication, impacts on social and professional function and can result in malnutrition and its associated morbidity and mortality.

SUMMARY

Small bowel dysmotility due to a neuropathy can result from acute or chronic disorders in the central and peripheral nervous system and includes the cerebral cortex, brain stem, spinal cord, parasympathetic (vagus) and sympathetic nerves and the myenteric and submucosal plexuses of the intestine. Generalized muscle disorders can also cause an enteral myopathy. Generally, the disorders may be degenerative or inflammatory. Both enteric neuropathy and myopathy may cause symptoms of abdominal pain, nausea/vomiting, bloating, constipation or diarrhoea and can cause malnutrition. The symptoms need to be addressed in order of importance to the patient and malnutrition prevented or treated.

Treatment of small intestinal disease in systemic sclerosis with octreotide: a prospective study in seven patients

BACKGROUND

Symptoms associated with small intestinal involvement in patients with systemic sclerosis (SSc) are usually severe and resistant to treatment.

OBJECTIVES

To assess the safety and efficacy of octreotide in refractory small intestinal disease complicating SSc.

METHODS

Seven female patients (aged from 37 to 64 years old) with SSc were included in the study. All of them had symptoms compatible with small bowel pathology, nonresponding to several prokinetic agents. The patients received either subcutaneous octreotide, 0.1 mg twice daily, or intramuscular octreotide LAR (long-acting-release), 20 mg/mo. Symptom severity was assessed at baseline and at various follow-up points in a scale of 0-3, for each symptom. Significant gastrointestinal pathology was excluded by gastroscopy, colonoscopy, and small bowel enemas before octreotide administration.

RESULTS

All patients responded to octreotide, and a significant reduction from symptom severity at baseline (mean +/- SD: 2.9 +/- 1.1) was noted even in the first following month (1.3 +/- 0.5, P = 0.0006). A significant disturbance of defecation in 2 patients improved dramatically. Short relapses were noticed in patients who were initially treated with subcutaneous octreotide. These patients were subsequently treated with octreotide LAR, resulting in an overall symptom reduction at 6 months (0.7 +/- 0.5, P = 0.003), which was sustained during follow-up (median follow-up: 14.4 months). No side effects were noted.

CONCLUSION

These results suggest that long-term treatment with octreotide LAR may be a safe and effective approach for treatment of small intestinal disease in patients with SSc.

Octreotide treatment of chronic intestinal pseudoobstruction secondary to connective tissue diseases

Chronic intestinal pseudoobstruction (CIPO) is a rare syndrome that may occur in association with connective tissue diseases (CTD). Effective management is a major challenge. We report 3 cases in which subcutaneous octreotide was efficacious in the treatment of digestive symptoms in CIPO. In 2 of the 3 cases, previous treatment with domperidone, cisapride, or erythromycin had been unsuccessful. All 3 patients underwent a regimen of oral antibiotics along with octreotide to stimulate small bowel motility. The effects of octreotide were evident within 48 hours after the first injection in all patients. In 2, the efficacy seemed to decrease after 1 week and 6 months respectively, but increasing the dosage led to another remission. CIPO in CTD is a severe condition that can evolve regardless of the underlying disease activity. Octreotide appears to be efficacious in improving both clinical symptoms and manometric patterns. When its therapeutic effect diminishes, increasing the dosage can be useful.

Trimebutine: mechanism of action, effects on gastrointestinal function and clinical results

The actions of trimebutine [3,4,5-trimethoxybenzoic acid 2-(dimethylamino)-2-phenylbutylester] on the gastrointestinal tract are mediated via (i) an agonist effect on peripheral mu, kappa and delta opiate receptors and (ii) release of gastrointestinal peptides such as motilin and modulation of the release of other peptides, including vasoactive intestinal peptide, gastrin and glucagon. Trimebutine accelerates gastric emptying, induces premature phase III of the migrating motor complex in the intestine and modulates the contractile activity of the colon. Recently, trimebutine has also been shown to decrease reflexes induced by distension of the gut lumen in animals and it may therefore modulate visceral sensitivity. Clinically, trimebutine has proved to be effective in the treatment of both acute and chronic abdominal pain in patients with functional bowel disorders, especially irritable bowel syndrome, at doses ranging from 300 to 600 mg/day. It is also effective in children presenting with abdominal pain.